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Blank Illinois Pre Participation Physical Form

The Illinois Pre Participation Physical form is a crucial document designed for athletes and their parents to complete before engaging in sports. This form gathers essential health information to ensure that young athletes are fit and safe to participate in physical activities. It includes questions about medical history, current medications, and specific health concerns, allowing healthcare professionals to assess any potential risks.

Outline

The Illinois Pre Participation Physical form plays a crucial role in ensuring the safety and well-being of student-athletes before they engage in sports activities. This comprehensive document requires detailed information about the athlete's medical history, including any medications, allergies, and previous health issues. Parents or guardians must provide accurate responses to a series of questions that cover general health, heart health, bone and joint conditions, and other medical concerns. Notably, the form also includes specific inquiries about family medical history, particularly regarding heart conditions, which can be vital for identifying potential risks. Additionally, the physical examination section assesses the athlete's overall health, including vital signs and a thorough check of various body systems. The form culminates in a consent section related to performance-enhancing substance testing, underscoring the commitment to fair play in athletics. By requiring this form, schools aim to protect students and promote a safe sporting environment.

Sample - Illinois Pre Participation Physical Form

Pre-participation Examination

To be completed by athlete or parent prior to examination.

Name

School Year

Last

First

Middle

Address

City/State

Phone No.

Birthdate

Age

Class

Student ID No.

Pare t’s Na e

Phone No.

Address

City/State

HISTORY FORM

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies?	 Yes	 No	If yes, please identify specific allergy below.
 Medicines			 Pollens	 Food	 Stinging Insects

E plain Yes answe s elow. Ci	le uestions ou don’t know the answe s to.


	GENERAL QUESTIONS				Yes	No
1.		Has a doctor ever denied or restricted your participation in sports
		for any reason?
2.		Do you have any ongoing medical conditions? If so, please identify
		below:  Asthma  Anemia  Diabetes  Infections
		Other: _	__________

3.		Have you ever spent the night in the hospital?
4.		Have you ever had surgery?
	HEART HEALTH QUESTIONS ABOUT YOU				Yes	No
5.		Have you ever passed out or nearly passed out DURING or AFTER
		exercise?
6.		Have you ever had discomfort, pain, tightness, or pressure in your
		chest during exercise?
7.		Does your heart ever race or skip beats (irregular beats) during
		exercise?
8.		Has a doctor ever told you that you have any heart problems? If
		so, check all that apply:  High blood pressure  A heart murmur
		 High cholesterol  A heart infection  Kawasaki disease
		Other: ___		______

9.		Has a doctor ever ordered a test for your heart? (For example,
		ECG/EKG, echocardiogram)
10.		Do you get lightheaded or feel more short of breath than
		expected during exercise?
11.		Have you ever had an unexplained seizure?
12.		Do you get more tired or short of breath more quickly than your
		friends during exercise?
	HEART HEALTH QUESTIONS ABOUT YOUR FAMILY				Yes	No
13.		Has any family member or relative died of heart problems or had
		an unexpected or unexplained sudden death before age 50
		(including drowning, unexplained car accident, or sudden infant
		death syndrome)?
14.		Does anyone in your family have hypertrophic cardiomyopathy,
		Marfan syndrome, arrhythmogenic right ventricular
		cardiomyopathy, long QT syndrome, short QT syndrome, Brugada
		syndrome, or catecholaminergic polymorphic ventricular
		tachycardia?
15.		Does anyone in your family have a heart problem, pacemaker, or
		implanted defibrillator?
16.		Has anyone in your family had unexplained fainting, unexplained
		seizures, or near drowning?
	BONE AND JOINT QUESTIONS				Yes	No
17.		Have you ever had an injury to a bone, muscle, ligament, or
		tendon that caused you to miss a practice or a game?
18.		Have you ever had any broken or fractured bones or dislocated
		joints?
19.		Have you ever had an injury that required x-rays, MRI, CT scan,
		injections, therapy, a brace, a cast, or crutches?
20.		Have you ever had a stress fracture?
21.		Have you ever been told that you have or have you had an x-ray
		for neck instability or atlantoaxial instability? (Down syndrome or
		dwarfism)
22.		Do you regularly use a brace, orthotics, or other assistive device?
23.		Do you have a bone, muscle, or joint injury that bothers you?
24.		Do any of your joints become painful, swollen, feel warm, or look
		red?
25.		Do you have any history of juvenile arthritis or connective tissue
		disease?

MEDICAL QUESTIONS

Yes

26.Do you cough, wheeze, or have difficulty breathing during or after exercise?

27.	Have you ever used an inhaler or taken asthma medicine?
28.	Is there anyone in your family who has asthma?
29.	Were you born without or are you missing a kidney, an eye, a
	testicle (males), your spleen, or any other organ?
30.	Do you have groin pain or a painful bulge or hernia in the groin
	area?
31.	Have you had infectious mononucleosis (mono) within the last
	month?
32.	Do you have any rashes, pressure sores, or other skin problems?
33.	Have you had a herpes or MRSA skin infection?
34.	Have you ever had a head injury or concussion?
35.	Have you ever had a hit or blow to the head that caused
	confusion, prolonged headache, or memory problems?
36.	Do you have a history of seizure disorder?
37.	Do you have headaches with exercise?
38.	Have you ever had numbness, tingling, or weakness in your arms
	or legs after being hit or falling?
39.	Have you ever been unable to move your arms or legs after being
	hit or falling?
40.	Have you ever become ill while exercising in the heat?
41.	Do you get frequent muscle cramps when exercising?
42.	Do you or someone in your family have sickle cell trait or disease?
43.	Have you had any problems with your eyes or vision?
44.	Have you had any eye injuries?
45.	Do you wear glasses or contact lenses?
46.	Do you wear protective eyewear, such as goggles or a face shield?
47.	Do you worry about your weight?
48.	Are you trying to or has anyone recommended that you gain or
	lose weight?
49.	Are you on a special diet or do you avoid certain types of foods?
50.	Have you ever had an eating disorder?
51.	Have you or any family member or relative been diagnosed with
	cancer?
52.	Do you have any concerns that you would like to discuss with a
	doctor?
FEMALES ONLY		Yes	No
53.	Have you ever had a menstrual period?

54.How old were you when you had your first menstrual period?

55.How many periods have you had in the last 12 months?

Explain es answe s he e

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete

Signature of parent/guardian

Date

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503

Pre-participation Examination

PHYSICAL EXAMINATION FORM

EXAMINATION

Height

Weight

 Male

 Female

(

)

Pulse

Vision R 20/

L 20/

Corrected

 Y  N

MEDICAL

NORMAL

ABNORMAL FINDINGS

Appearance

• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum,

arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat

Pupils equal

Hearing

Lymph nodes

Heart a

Murmurs (auscultation standing, supine, +/- Valsalva)

Location of point of maximal impulse (PMI)

Pulses

Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)b

Skin

HSV, lesions suggestive of MRSA, tinea corporis

Neurologic c

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/Ankle

Foot/toes

Functional

Duck-walk, single leg hop

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.

bConsider GU exam if in private setting. Having third party present is recommended.

cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

O the

asis of the e a i

atio

o this da

, I appro e this

hild’s parti ipatio i

i ters holasti

sports for o

e year.

Yes

Limited

Examination Date

Additional Comments:

Ph	si ia	’s Sig ature
Ph	si ia	’s Assista t Sig ature*
Ad a ed Nurse Pra titio er’s Sig ature*
*effective January 2003, the IHSA Board of Dire tors appro ed a re o			e datio , o siste t ith the Illi ois S hool Code, that allo s Ph si ia ’s Assista ts or
Advanced Nurse Practitioners to sign off on physicals.

IHSA Steroid Testing Policy Consent to Random Testing

(This section for high school students only)

2011-2012 school term

As a prerequisite to participation in IHSA athletic activities, we agree that I/our student will not use performance-enhancing substances as defined in the IHSA Performance-Enhancing Substance Testing Program Protocol. We have reviewed the policy and understand that I/our student may be asked to submit to testing for the presence of performance-enhancing substances in my/his/her body either during IHSA state series events or during the school

day, and I/our student do/does hereby agree to submit to such testing and analysis by a certified laboratory. We further understand and agree that the results of the performance-enhancing substance testing may be provided to certain individuals in my/our student’s high school as specified in the IHSA

Performance-Enhancing Substance Testing Program Protocol which is available on the IHSA website at www.IHSA.org. We understand and agree that the results of the performance-enhancing substance testing will be held confidential to the extent required by law. We understand that failure to provide accurate and truthful information could subject me/our student to penalties as determined by IHSA.

A complete list of the current IHSA Banned Substance Classes can be accessed at

http://www.ihsa.org/initiatives/sportsMedicine/files/IHSA_banned_substance_classes.pdf


	Signature of student-athlete		Date		Signature of parent-guardian		Date

Click for PDF

Form Information

Fact Name	Details
Purpose	The Illinois Pre-Participation Physical form is designed to assess an athlete's health and fitness before participating in sports.
Completion Requirement	The form must be completed by the athlete or their parent prior to the physical examination.
Medical History	It includes questions about medical history, current medications, allergies, and previous injuries.
Heart Health Assessment	Specific heart health questions are included to evaluate potential risks related to cardiovascular conditions.
Family Medical History	The form asks about family history of heart problems and other significant medical issues.
Governing Law	This form is governed by the Illinois School Code, which outlines requirements for student-athlete health assessments.
Signature Requirement	Both the athlete and a parent or guardian must sign the form, indicating their acknowledgment of the information provided.

Detailed Guide for Filling Out Illinois Pre Participation Physical

Completing the Illinois Pre Participation Physical form is essential for student-athletes before they can participate in sports. This process involves providing personal information, medical history, and consent for testing. Follow the steps outlined below to ensure the form is filled out accurately.

Begin by entering the athlete's name in the designated fields: last name, first name, and middle name.
Fill in the address, including city and state, and provide a contact phone number.
Record the athlete's birthdate, age, class, and student ID number.
Provide the parent's name and contact phone number, along with their address, including city and state.
List any medicines and allergies the athlete is currently taking or has, checking "Yes" or "No" for allergies and specifying if applicable.
Answer the general questions regarding past medical history, marking "Yes" or "No" for each question.
Complete the heart health questions about the athlete's personal and family history, marking "Yes" or "No" as appropriate.
Respond to the bone and joint questions regarding any past injuries or conditions, again marking "Yes" or "No."
Fill out the medical questions section, indicating any relevant issues or conditions.
If applicable, complete the females only section regarding menstrual history.
Sign and date the form at the bottom, confirming that the information provided is accurate and complete.

After completing the form, it should be submitted to the designated healthcare provider for review and physical examination. Ensure that all sections are filled out thoroughly to avoid delays in processing. Follow any additional instructions provided by the school or healthcare provider regarding the next steps in the physical examination process.

Obtain Answers on Illinois Pre Participation Physical

What is the purpose of the Illinois Pre Participation Physical form?
The Illinois Pre Participation Physical form is designed to assess an athlete's physical health before they participate in sports. It helps identify any medical conditions or risk factors that could affect their ability to safely engage in athletic activities. This form must be completed by the athlete or their parent before the physical examination.
Who needs to complete the form?
All student-athletes in Illinois who wish to participate in school sports must complete the Illinois Pre Participation Physical form. This includes students of all ages and sports disciplines. The form must be filled out accurately to ensure the safety and well-being of the athlete.
What information is required on the form?
The form requires various personal details, including:
- Name
- School year
- Address and contact information
- Birthdate and age
- Medical history, including any medications, allergies, and past injuries
This information helps healthcare providers evaluate the athlete's readiness for sports participation.
What should I do if I have a medical condition?
If the athlete has a medical condition, it is crucial to disclose this on the form. The form includes specific questions about ongoing medical issues, past surgeries, and any heart-related concerns. Providing complete and honest information allows healthcare professionals to make informed decisions about the athlete's health and safety.
How often do I need to submit this form?
The Illinois Pre Participation Physical form must be submitted annually. Each school year requires a new form to ensure that the athlete's health status is up-to-date. This annual requirement helps schools monitor any changes in the athlete's health that could impact their participation in sports.
What happens after the form is completed?
Once the form is completed, it must be submitted to the school's athletic department. A healthcare provider will review the information and conduct a physical examination. If the athlete is cleared for participation, the provider will sign the form, indicating that the athlete is fit to play. If there are concerns, the provider may recommend further evaluation or restrictions.

Common mistakes

Completing the Illinois Pre Participation Physical form is an essential step for athletes, but mistakes can occur that may delay or complicate the process. One common error is failing to provide complete and accurate medical histories. Athletes or parents may overlook important details about past injuries, surgeries, or ongoing medical conditions. This information is crucial for healthcare providers to assess the athlete’s fitness for participation in sports. Omitting details can lead to misunderstandings or even jeopardize the athlete's health during physical activities.

Another frequent mistake is neglecting to disclose all medications and allergies. When filling out the section regarding medicines and allergies, individuals sometimes forget to list over-the-counter medications or supplements they are taking. This oversight can be problematic, especially if an athlete has an allergic reaction or requires medical attention during a sporting event. It is vital to provide a comprehensive list to ensure that medical professionals have all the necessary information to respond effectively in case of an emergency.

In addition, many people fail to answer all questions thoroughly. Some may leave questions blank or check "no" without considering the implications. For example, questions related to heart health or previous injuries are critical for determining an athlete's readiness to compete. Each question is designed to gather essential information, and skipping them could lead to serious consequences. It is important to take the time to read each question carefully and respond honestly.

Lastly, misunderstanding the significance of the signatures required on the form can lead to complications. Both the athlete and a parent or guardian must sign the document, indicating their acknowledgment of the information provided. Failing to secure both signatures can render the form invalid. This step is not merely a formality; it signifies that both parties understand the athlete’s health status and agree to the terms outlined in the document. Ensuring that all signatures are present is a simple but vital step in the process.

Documents used along the form

When preparing for athletic participation in Illinois, several forms accompany the Illinois Pre Participation Physical form. Each document serves a specific purpose to ensure the health and safety of student-athletes. Below is a list of essential forms often required alongside the physical examination.

Emergency Contact Form: This document provides crucial information about who to contact in case of an emergency during practices or games.
Health Insurance Information: This form collects details about the athlete's health insurance coverage, ensuring that medical expenses can be addressed if needed.
Parental Consent Form: Parents or guardians must sign this document, giving permission for their child to participate in sports activities.
Concussion Awareness Form: This form educates athletes and their families about the risks of concussions and requires acknowledgment of understanding these risks.
Medical History Form: A comprehensive record of the athlete's past medical issues, surgeries, and ongoing conditions helps healthcare providers make informed decisions.
Medication Authorization Form: If an athlete requires medication during school or practice, this form allows parents to authorize school personnel to administer it.
Sports-Specific Risk Acknowledgment: This document outlines the specific risks associated with the sport and requires the athlete and parent to acknowledge understanding of these risks.
Code of Conduct Agreement: Athletes must agree to adhere to the school's code of conduct, which outlines expected behavior and responsibilities during participation.
Physical Activity Readiness Questionnaire (PAR-Q): This form assesses the athlete's readiness for physical activity and identifies any potential health concerns.
Transportation Permission Form: This document grants permission for the athlete to travel to and from practices and games, often required for school-sponsored transportation.

Having these documents prepared and submitted is vital for ensuring a smooth and safe athletic experience. Each form plays a role in safeguarding the health of student-athletes and fostering a supportive environment for participation in sports.

Similar forms

The Illinois Pre Participation Physical form shares similarities with several other documents used in sports and health contexts. Here are four documents that are comparable:

Sports Physical Form: Like the Illinois form, a sports physical form is required for athletes before participating in sports. It assesses the athlete's health status, identifies any medical conditions, and ensures they are fit for competition.
Health History Questionnaire: This document collects detailed information about an individual’s medical history, including past illnesses, surgeries, and allergies. Similar to the Illinois form, it helps healthcare providers understand any potential risks related to sports participation.
Emergency Contact Form: An emergency contact form is essential for athletes in case of injury or medical emergencies. It provides vital information about whom to contact and the athlete's medical history, paralleling the Illinois form's focus on health and safety.
Consent to Treat Form: This form gives permission for medical professionals to provide treatment in emergencies. It shares the goal of ensuring that the athlete receives appropriate care, much like the Illinois form aims to safeguard the athlete's health during sports activities.

Dos and Don'ts

When filling out the Illinois Pre Participation Physical form, it's important to be thorough and accurate. Here are some guidelines to help you navigate the process effectively.

Do provide complete and accurate information about your medical history.
Do list all medications and supplements you are currently taking.
Do answer all questions honestly, even if you are unsure about some answers.
Do ensure that both the athlete and parent/guardian sign the form.
Don't leave any sections blank; incomplete forms can delay the process.
Don't omit any past medical conditions or surgeries, as this information is crucial for your safety.

Misconceptions

Misconception 1: The form is only for students with known medical issues.

This is not true. The Illinois Pre Participation Physical form is designed for all student-athletes, regardless of their medical history. It helps identify potential health risks that may not be apparent, ensuring that every athlete is fit to participate in sports safely.

Misconception 2: Parents can skip sections they think are irrelevant.

Every section of the form is important. Skipping questions can lead to missing critical health information. Each question is crafted to gather comprehensive details about the athlete's health, which can influence their safety and performance.

Misconception 3: The physical examination is a one-time requirement.

In fact, the physical examination must be completed annually. This ensures that any changes in the athlete's health are monitored regularly, providing updated information for their safety in sports.

Misconception 4: Only a physician can complete the form.

While a physician's signature is required, advanced nurse practitioners and physician assistants can also sign off on the physical examination. This flexibility allows for more accessible healthcare options for families.

Misconception 5: The form is only about physical health.

The form addresses various aspects of health, including mental and emotional well-being. Questions about weight, diet, and previous injuries help create a holistic view of the athlete's health, which is crucial for their overall performance and safety.

Key takeaways

Filling out the Illinois Pre Participation Physical form is an important step for student-athletes. Here are some key takeaways to keep in mind:

Complete All Sections: Ensure that every section of the form is filled out accurately. This includes personal information, medical history, and any current medications.
Be Honest: Provide truthful answers, especially regarding medical history and any ongoing conditions. This information helps healthcare providers assess the athlete's fitness for participation.
Consult with a Doctor: If there are any concerns or unclear answers, it’s best to discuss them with a healthcare professional before submitting the form.
Parental Involvement: Parents or guardians should review the form with their child. Their signature is required, emphasizing the importance of understanding the information provided.
Stay Updated: Keep a copy of the completed form for your records. If any health changes occur, update the form and notify the coach or athletic department.

These steps can help ensure a smooth process for student-athletes as they prepare for participation in sports.